Healthcare Provider Details

I. General information

NPI: 1457569402
Provider Name (Legal Business Name): RADY CHILDREN'S HOSPITAL SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 WARING RD
OCEANSIDE CA
92056-4404
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC 5010
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 760-758-1620
  • Fax: 858-966-5828
Mailing address:
  • Phone: 858-966-5817
  • Fax: 858-966-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: MR. ROGER G ROUX
Title or Position: SR VICE PRESIDENT CFO
Credential: MBA
Phone: 858-576-1700